Susan Friedman, MD, MPH Krupa Shah, MD, MPH

University of Rochester Division of Aging 10th Annual Caring For Elders Program

Burgundy Basin Inn April 27, 2016

The aging of America – opportunities and challenges • Demographics; what does “extreme aging” look like?

• Changes in health / chronic disease

• Presence / role of geriatricians

The Blue Zone approach • Principles

• Replication

Behavioral change

Practical ideas to “Blue Zone” your life

Na ta ekatostisis (may you live to be 100). (Greek)

May you live to be 100 years, with one extra year to

repent. (Irish)

May you live to be 120. (Jewish)

May you die in bed at 95, shot by a jealous spouse. (Irish)

May you live to be 100 and may the last voice you hear be

mine. (Frank Sinatra)

Sto lat, sto lat, niech zyje zyje nam (Good luck, good

cheer, may you live a hundred years). (Polish)

6% married

17% live in poverty

Dementia – 37% of those age 90+

Functional status

◦ Over 80% with some activity of daily living impairment

Independence

◦ 15% live alone

◦ 48% live in nursing homes

Centenarians in the US. US Census Bureau, 1999

Kincel B, The Centenarian Population 2007-2011, US Census Bureau, 2014.

Neuroepidemiology. 2007 November; 29(1-2): 125–132

Lived 1875 - 1997

Father lived to almost 100, mother

86, brother 97

Outlived her husband, daughter and

grandson

Met Vincent Van Gogh when she was

13

Saw Eiffel Tower being built

Took up fencing at 85

Lived on her own to 110

Oldest person ever in a movie (114)

Ascribed longevity to olive oil, port

wine and chocolate

Year Life

expectancy

1800 26

1900 47.3 (US)

2013 78.8 (US)

Of all the people who have lived to be 65 or older, half are currently alive.

0

100

200

300

400

500

600

700

2015 2020 2030 2040 2050 2060

Thousands

US Census Bureau, 2014 National Population Projections

NEJM 1980; 303: 130-5.

OR

“The failure of success” - Ernest Gruenberg Milbank Q. 2005 Dec; 83(4): 779–800.

Hippocrates

460 BCE

Never smoker

BMI < 30

Physical activity ≥ 3.5 hours per week

High intake fruits/veg/whole grain, low meat

Ford et al., Arch Intern Med 2009;169(15):1355-62

Arch Intern Med. 2008;168(3):284-290.

Physician’s health study

2,357 men

Ave age 72

5 risk factors:

◦ Smoking ◦ DM ◦ HTN ◦ Obesity ◦ Sedentary lifestyle

Released 2010

2020 Impact Goal

Control risk / promote health

Aim: ◦ ↑ cardiovascular

health by 20%

◦ ↓ CVD and stroke deaths by 20%

“Primordial prevention”

4 health behaviors ◦ Non-smoking

◦ BMI < 25

◦ Physical activity at goal

◦ DASH diet

3 ideal health factors ◦ Total chol < 200

◦ Untreated BP < 120/80

◦ Untreated FPG < 100

Lloyd-Jones et al. Circulation. 2010;121:586-613.

2000

Obesity Trends Among U.S. Adults Behavioral Risk Factor Surveillance System , 1990, 2000, 2010

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

CDC, 2015

0%

10%

20%

30%

40%

50%

60%

Women Men

1988-1994

2009-2010

Ladabaum et al, Am J Med, 2014; 127(8):717-727.

Data from NHANES survey

Healthy people 2010 target

75% consuming ◦ 2 or more servings of fruit

50% consuming ◦ 3 or more servings of

vegetables Vegetables

Fruit

Heart SCORE study

1933 participants

Mean age 59

Community dwelling

Allegheny Cty, PA

66% women

44% African American

1 person had all 7 components

Ave of 2.3

5.3% with 5 or more

Less with ◦ Age

◦ Lower income

◦ African American

Bambs et al. Circulation. 2011; 123(8): 850–857.

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

No chronic disease 4+ chronic diseases

1998

2004

2008

Hung et al. BMC Geriatrics 2011;11:47-58.

0%

20%

40%

60%

80%

HTN Diabetes Cancer COPD Arthritis

1998

2004

2008

Hung et al. BMC Geriatrics 2011;11:47-58.

Changes in mobility disability

0

10

20

30

40

50

60

50-59 60-69 70-79 80+

1998

2006

0

10

20

30

40

50

60

50-59 60-69 70-79 80+

1998

2006

Crimmins et al. J Gerontology Soc Sci 2011; 66B: 75-86.

Women Men

Over age 85

Dependent in activities of daily living

Complex biomedical problems ◦ Multimorbidity

◦ Polypharmacy

Complex psycho-medical situations ◦ Dementia

◦ Depression

Frail

Geriatric syndromes

Warshaw et al. J Am Geriatr Soc 2008;56:1796-1801.

0

1000

2000

3000

4000

5000

6000

7000

8000

2004 2014

Certificates

Certificates

198 201 201 204 200 186

175 178

162 154 135

0

50

100

150

200

20042005200620072008200920102011201220132014

Acti

ve C

ert

ific

ate

s (per

1

million b

enefi

cia

ries)

Year

* Aged 65 and over

Rapidly increasing older adult population

Increasing prevalence of chronic disease

Evidence of increases in disability

Limited number of geriatricians and PCPs

How do we address this?

Interest in health and physical fitness

Active in their own medical care

Information age

Pro-active

Self-motivated

Areas of highest longevity

Live “better” as well as longer

Named for demographers’ maps

Personal interviews

Looked for commonalities

Icaria, Greece • Highest % of 90 year olds on the planet • Almost 1 in 3 reach 90 • 20% less cancer, 50% less heart disease, almost no dementia

Move naturally

Hara hachi bu

Plant slant

Drink alcohol, especially red wine, in moderation

Ikigai or plan de vida - purpose

Reduce stress

Belong to a spiritual community

Keep family first

Surround yourself with people who have similar blue zone

values

The “3-legged stool”

Ikaria Rochester

Albert Lea, MN

• Town of 18,500

• 7 lakes

• History as meatpacking town

• 60-65% overweight or obese

• AARP / United Health Foundation

Town meetings

Personal pledge

Community gardens

Walking and bike paths

Changes in ◦ Restaurants

◦ Schools

◦ Grocery stores

◦ Workplace

“Purpose” workshops

Walking moais

Walking school bus

Community participation

◦ 60% of the city’s restaurants

◦ 51% of employers

◦ 100% of its schools

◦ 27% of citizens

◦ 150 “ambassadors”

• Ave life expectancy increased 3.1 years

• Ave wt loss of 2.8 lbs. each

• 21% drop in absenteeism

• 49% decrease in health care costs in city employees

Buettner, The Blue Zones Solution, 2015.

California Beach cities ◦ Manhattan Beach

◦ Hermosa Beach

◦ Redondo Beach

15 cities and towns in Iowa

Naples, FL

Hawaii

Oregon

Texas

Behavior change in older persons present special challenges: ◦ multiple comorbidities

◦ sensory impairments

◦ reduced mobility

◦ psychosocial factors (loneliness, depression, loss of identity)

◦ dependency

Health behaviors influenced by social network ◦ Smoking ◦ Obesity ◦ Happiness

Influence extends to 3 degrees of separation

42

Christakis and Fowler, N Engl J Med 2007;357:370-9. N Engl J Med 2008;358:2249-58.

British Medical Journal 337 (337): a2338

Movement from South Asia to Europe

Complex changes

Primary trends ◦ Increase in energy and fat intake

◦ Reduction in carbohydrates

◦ Switch from whole grains to more refined sources

◦ Decrease in fiber

◦ More meat and dairy

Higher incidence of ◦ DM2

◦ Obesity

◦ CVD Holmboe-Ottesen et al, Food and Nutrition Research 2012, 56:18891.

To get moving in your Blue Zone, try some of these tips.

Inconvenience yourself

Have fun. Keep moving.

Walk

Make a date

Plant a garden

Enroll in a yoga class

Ergonomic work station

Activity ≠ exercise

To follow 80 % rule in your Blue Zone, try the following tips

Serve and store

Make food look bigger

Use small vessels

Make snacking a hassle

Give yourself a daily reminder

Buy smaller packages

To follow 80 % rule in your Blue Zone, try the following tips

Eat more slowly

Focus on food

Have a seat

Eat early

Try these tips to incorporate more plants in your diet Eat four to six vegetable servings daily

Limit intake of meat

Showcase fruits and vegetables

Lead with beans

Eat nuts every day

Stock up

Introduce a glass of wine into a daily routine

Buy a case of high-quality red wine.

Treat yourself to a “Happy Hour”

Take it easy

To realize your purpose, try the following tips

Craft a personal mission statement

Find a partner

Learn something new

Use these tips to find a quiet space to slow down in your Blue Zone

Reduce the noise

Be early

Meditate

Sleep

De-clutter

To strengthen the spiritual dimension of your Blue Zone, try these tactics

Spiritual does not have to mean religious

Be more involved

Explore a new tradition

Just go

These tips can help you create your family’s Blue Zone.

Get closer

Establish routines ◦ Meals

◦ Holidays

Put family first

Try these tips to build up the inner circle of your Blue Zone

Identify your inner circle.

Don’t be a grump!

Create time together

Create a moai

Timing – we are seeing changes in Demographics

Health trends

Healthcare reform

Changes in lifestyle make a big difference!

The Blue Zones focus on Activity

Nutrition

Connectedness